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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E'. t 1 01 RUBBER LINED d 1 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1�4 07 UNLINED 1 1 08 UNKNOWN f 1 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 1 1 OZ VINYL WRAPPING ( 1 O'S CATHODIC PROTECTION ( 1 04 U1(KNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT f 1 09 OTHER' <br /> VI f IPING <br /> A. ABOVEGP.OUNO PIPING= ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH i ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UtrOERGROUND PIPING- ( 1 01 DOUDLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ix! 04 PRESSURE ( ) 05 SUCTION l 1 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GP.OUI(D WATER H04ITORING WELLS 1 1 07 PRESSURE TEST ( 1 09 NONE 1 ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT PEQU.RED TO COMPLETE THIS S€CTION <br /> .CURiENTLY PPEVIOUSLY DELETE CASH IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> 1 ) O 1 ( 1 02 1 1 113 L � <br /> ' 1 1 01 ( I 02VI 1 03 fIl 1� �l 11 1j1 11 l <br /> 1 1 01 ( 1 02 -1 1 03 1 I I 1 JI1- -1 1 -- -- <br /> 1 ) 01 [ 1 02 ( 1 03 <br /> 1 1 01 _ ( } 02 —( 1 03 <br /> 1 ) 01 1 1 02 1 DLLI I I I I I I I IJ 1 J - <br /> 1 01— 1 1 02 f 1 D1 ' _I I�I I � — <br /> r-} <br /> 01 —f 1 02 �1 1 c13 _J�1_1-H <br /> 11 <br /> 01 i -1-02 f I 03 <br /> R I il� 1 1 1 1 I I IA �- <br /> _1_ <br /> 115 CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 42 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> iv!_ ..'4 FII1' PSI AT E ] 4l <br /> ` PHONC iAR 'E <br /> EA C O �` -7 J _ <br /> �._. <br /> LOP. tOCAL AGENCY USC ONLY <br /> CITY COCE COUrtTv CODE <br /> 4, (2j�( _3 <br /> Lo c <br /> "1 1 <br /> ICO'1:AfT c=r^1,14 PHONE tai ARCA COLE <br /> CAT[ p• LOST <br /> SECTION JIN COr^alJANCC Pf9mj t A{+PAc7VAL OAT <br /> C �TAANSACYION CATC �LOC4L PEanIT 70 a <br /> t I Cl `ES � I 02 1;0 _._ .. _ __ . <br /> ,)iC04-C')lr'.5 PAGE Z' <br />